Basic Information
| Provider Information | |||||||||
| NPI: | 1548338171 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STERN | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | LEONARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD STE 520 | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 8667954020 | ||||||||
| Practice Location | |||||||||
| Address1: | 7810 WORMANS MILL RD | ||||||||
| Address2: | |||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217013035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3012282666 | ||||||||
| FaxNumber: | 3012282119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2006 | ||||||||
| LastUpdateDate: | 01/31/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 0618001421 | VA | N | Eye and Vision Services Providers | Optometrist | 152W00000X | OPC1448 | FL | N | Eye and Vision Services Providers | Optometrist | 152W00000X | OE005427P | PA | N | Eye and Vision Services Providers | Optometrist | 152W00000X | TA0761 | MD | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 024303500 | 05 | MD | MEDICAID | 60997503 | 01 | MD | CAREFIRST BCBS | OTHER | 410046898 | 01 | RAILROAD MEDICARE | OTHER |